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Objective: Wound, ischemia, and foot infection (WIfI) staging was established to provide objective classification in patients with chronic limb threatening ischemia (CLTI) and to predict 1-year major amputation risk. Our goal was to validate WIfI staging using data from the Best Endovascular versus Best Surgical Therapy in Patients with CLTI (BEST-CLI) trial., Methods: Data from the BEST-CLI Trial, a prospective randomized trial comparing surgical (OPEN) and endovascular (ENDO) revascularization, were used to assess the association of WIfI stage on long-term outcomes in an intention to treat analysis. Patients were prospectively allocated to two cohorts - cohort 1 and 2 - which included patients with and without adequate single segment greater saphenous vein (SSGSV), respectively. The primary outcome of this analysis was major amputation., Results: There were 1,568 patients analyzed, representing 86% of the entire trial population; of these 35.5%, 29.6% and 34.9% were categorized as WIfI 4, WIfI 3, and WIfI 1/2, respectively. There were 1223 patients (606 OPEN, 617 ENDO) and 345 patients (OPEN 172, ENDO 173) in cohorts 1 and 2, respectively. On unadjusted Kaplan-Meier analysis, WIfI clinical stages 4 and 3, compared to WIfI 1/2, were associated with higher rates of major amputation (21.4%, 16.2% vs. 10.7%), death (33.5%, 35.7% vs. 24.6%), amputation/death (44.9%, 44.5% vs. 31.3%), MALE/death (34.4%, 33.9% vs. 29.5%), and reintervention/amputation/death (69.9% vs. 69% vs. 60.4%) (P<.05 for all) at 3 years. On risk adjusted analysis, compared to WIfI 1/2, major amputation was associated with WIfI 4 (HR 2.06, 95% CI 1.44 - 2.96, P<.001) and WIfI 3 (HR 1.62, 95% CI 1.1-2.37, P=.013) stages. Death was associated with both WIfI 4 (HR 1.3, 95% CI 1.03 - 1.63, P=.027) and WIfI 3 (HR 1.42, 95% CI 1.13-1.79, P=.003). MALE/death was associated with WIfI 4 (HR 1.29, 95% CI 1.02 - 1.63, P=.036. Reintervention amputation/death was associated with WIfI 4 (HR 1.28, 95% CI 1.09 - 1.50, P=.03) and WIfI 3 (HR 1.22, 99% CI 1.03 - 1.43), P=.018). When examining OPEN vs. ENDO revascularization by each WIfI stage, OPEN intervention was favored in cohort 1 for MALE/death for each stage., Conclusion: In BEST-CLI WIfI stage was strongly associated with major amputations, death, and MALE/death after revascularization for CLTI. Cohort 1 patients, with adequate preoperative SSGSV, had lower MALE/death with OPEN intervention across all WIfI stages. This validation of WIfI score in a prospective multicenter trial reinforces its importance in shared-decision making, informed consent, and prognostication., (Copyright © 2024. Published by Elsevier Inc.)

Rationale & Objective: Race and ethnicity differences exist in the type of arteriovenous access (AVA, including fistulas and grafts) used at hemodialysis (HD) initiation. The preferred anatomic location for the creation of an initial HD AVA is typically in the forearm We evaluated race and ethnicity differences in the use of an AVA in the forearm location at HD initiation., Study Design: Retrospective cohort study., Setting & Participants: Using records from DaVita Kidney Care linked to the US Renal Data System (USRDS), we evaluated patients aged≥16 years who initiated in-center HD with an AVA between 2006 and 2019., Predictor: Race and ethnicity, categorized as non-Hispanic White, non-Hispanic Black, Hispanic, or Other., Outcome: Forearm versus upper arm AVA location., Analytical Approach: Multivariable modified Poisson regression to estimate adjusted trends in AVA location over time and race and ethnicity differences in AVA location. Nested models helped assess the relative confounding by groups of variables on estimates of race and ethnicity differences., Results: Among 70,147 patients (51.7% White, 28.8% Black, 12.6% Hispanic, 6.9% Other), White patients were older and more likely to have peripheral vascular disease but less likely to have diabetes compared with the other groups. The proportion initiating HD using a forearm AVA decreased from 49% in 2006 to 29% in 2019 and by 3.6% (95% CI, 3.3%-3.9%) annually, with no difference in this trend among groups (race and ethnicity by calendar year interaction P=0.32). Black patients were 13% (95% CI, 10%-15%) less likely and Hispanic patients were 5% (95% CI, 1%-9%) less likely than White patients to initiate HD with a forearm AVA., Limitations: Findings may not apply to home HD., Conclusions: Use of a forearm AVA for HD initiation has declined and racial differences have persisted, with Black and Hispanic patients being less likely than White patients to have an AVA in the forearm location. Research toward understanding the causes and consequences of these trends and disparities is warranted., (Copyright © 2024 National Kidney Foundation, Inc. All rights reserved.)

Medicaid coverage among patients with peripheral artery disease (PAD) has been associated with higher rates of primary amputations. We sought to determine the relative contributions of clinical, demographic, and hospital factors to leg amputations among Texas Medicaid patients. Patient-level data were used to identify patients who underwent treatment for PAD-related foot complications in Texas. Patients were categorized into groups by insurance provider (Medicaid, Medicare, dual-enrollee, commercial, and provider network). Individual- and area-level multivariate analyses were used to find associations with primary amputation. Of 21,592 patients identified, 8.8% were covered by Medicaid, 35.3% by Medicare, 27.8% by Medicare and Medicaid, 7.3% by commercial insurance, and 20.7% by a provider network. Compared with commercially insured patients, Medicaid patients more often underwent amputation (33% v 49%), were categorized as Black or Hispanic (45% v 64%), presented with gangrene (61% v 71%), were admitted through an emergency department (61% v 73%), and were admitted to a safety net hospital (3% v 16%). They had lower relative rates of outpatient evaluation (1.33 v 0.55) and their hospitalizations were less centralized (Gini coefficient 0.43 v 0.39) (P < .001 for all). Amputations among Medicaid patients were associated with infection and gangrene, care at safety net hospitals, rate of outpatient visits, and Black and Hispanic race, even after risk-adjustment (P < .001). Leg amputations among Medicaid patients were associated with race, disease severity, hospital characteristics, and outpatient evaluation rates, but not with provider density and location. Focusing efforts on preventative care and early outpatient referrals could help address this disparity., (Copyright © 2022 Elsevier Inc. All rights reserved.)

Introduction: The Society for Vascular Surgery Threatened Limb Classification System ('WIfI') is used to predict risk of limb loss and identify peripheral artery disease in patients with foot ulcers or gangrene. We estimated the diagnostic sensitivity of multiple clinical and noninvasive arterial parameters to identify chronic limb-threatening ischemia (CLTI)., Methods: We performed a single-center review of 100 consecutive patients who underwent angiography for foot gangrene or ulcers. WIfI stages and grades were determined for each patient. Toe, ankle, and brachial pressure measurements were performed by registered vascular technologists. CLTI severity was characterized using Global Limb Anatomic Staging System (GLASS stages) and angiosomes. Medial artery calcification in the foot was quantified on foot radiographs., Results: GLASS NA (not applicable), I, II, and III angiographic findings were seen in 21, 21, 23, and 35 patients, respectively. A toe-brachial index < 0.7 and minimum ipsilateral ankle-brachial index < 0.9 performed well in identifying GLASS II and III angiographic findings, with sensitivity rates 97.8% and 91.5%, respectively. The diagnostic accuracy rates of noninvasive measures peaked at 74.7% and 89.3% for identifying GLASS II/III and GLASS I+ angiographic findings, respectively. The presence of medial artery calcification significantly diminished the sensitivity of most noninvasive parameters., Conclusions: The use of alternative noninvasive arterial testing parameters improves sensitivity for detecting PAD. Abnormal noninvasive results should suggest the need for diagnostic angiography to further characterize arterial anatomy of the affected limb. Testing strategies with better accuracy are needed.

Anemia of inflammation, as found in many chronic disease states, is common among persons with diabetic foot infections but is typically mild and self-limited. Herein we present four cases of patients with foot infections accompanied by severe anemia (nadir hemoglobin <8 gm/dL and resulting in transfusion of 4 + units of blood) as well as significant weight loss (30 + pounds), hyponatremia (<135 mmol/L), hypoalbuminemia (nadir <2 gm/dL), uremia and other metabolic derangements., (Copyright © 2022. Published by Elsevier Ltd.)

Background: Studies have shown that Medicaid coverage is associated with higher rates of primary amputation among patients with peripheral artery disease (PAD). We sought to identify whether hospital payer makeup also influences outcomes among these patients., Methods: Patients who underwent treatment for foot complications in Texas were identified and aggregated by hospital. Hospitals were grouped by payer mix: low-income payer predominant versus high-income payer predominant. Variance analyses were used to find differences between the groups. Individual and hospital-level regression analyses were used to find associations with amputation rates., Results: Out of 21,592 patients, 9,098 (42%) underwent amputation. They presented to 337 hospitals out of which 49 (15%) had a low-income predominant payer mix, and 109 (32%) had a high-income predominant payer mix. Patients at low-income payer predominant hospitals were more likely to present with gangrene (0.74 vs. 0.65, P < 0.01), undergo emergency admissions (0.67 vs. 0.50, P < 0.01), undergo amputation (0.53 vs. 0.42, P < 0.05), and incur higher per-day charges ($8,145 vs. $6,790, P < 0.05). At the individual level, despite risk-adjusting for disease-specific factors, amputation rate was associated with hospital payer mixes with greater proportions of Medicaid and lower proportions of commercially insured patients. At the hospital level, amputation rate was associated with higher proportion of Medicaid patients in hospital payer mix, lower hospital volumes, lower per-day charges, and higher gangrene and osteomyelitis rates (R 2  = 0.30, P < 0.01)., Conclusions: Higher proportion of Medicaid patients in a hospital payer mix is associated with an increased risk of primary amputation for PAD patients regardless of insurance coverage., (Copyright © 2022 Elsevier Inc. All rights reserved.)

Background: That foot infections are predominately polymicrobial has long been recognized, but it is not clear if the various species co-occur randomly or in patterns. We sought nonrandom species co-occurrence patterns that might help better predict prognosis or guide antimicrobial selection., Methods: We analyzed tissue (bone, skin, and other soft tissue), fluid, and swab specimens collected from initial foot infection episodes during a 10-year period using a hospital registry. Nonrandom co-occurrence of microbial species was identified using simple pairwise co-occurrence rates adjusted for multiple comparisons, Markov and conditional random fields, and factor analysis. A historical cohort was used to validate pattern occurrence and identify clinical significance., Results: In total, 156 unique species were identified among the 727 specimens obtained from initial foot infection episodes in 694 patients. Multiple analyses suggested that Staphylococcus aureus is negatively associated with other staphylococci. Another pattern noted was the co-occurrence of alpha-hemolytic Streptococcus , Enterococcus fecalis , Klebsiella , Proteus , Enterobacter , or Escherichia coli , and absence of both Bacteroides and Corynebacterium . Patients in a historical cohort with this latter pattern had significantly higher risk-adjusted rates of treatment failure., Conclusions: Several nonrandom microbial co-occurrence patterns are frequently seen in foot infection specimens. One particular pattern with many Proteobacteria species may denote a higher risk for treatment failure. Staphylococcus aureus rarely co-occurs with other staphylococci., (Published by Oxford University Press on behalf of Infectious Diseases Society of America 2022.)

Background: Screening identifies intact abdominal aortic aneurysms (iAAAs) before progression to ruptured AAAs (rAAAs). However, screening efforts have been limited by the low overall diagnostic yield and unequal screening among minority populations. The goal of the present study was to identify equitable AAA screening strategies for both majority and minority populations., Methods: We performed epidemiologic and geospatial analyses of inpatient and outpatient procedures for iAAAs and rAAAs at Texas hospitals from 2006 through 2014 at all nonfederal hospitals and clinics in Texas. The data were aggregated by area (metropolitan statistical area vs rural region) and then supplemented by six additional data sources to estimate the AAA repair incidence rates, rates of AAA-related clinic and ultrasound visits, travel distance to providers, and the location and number of unrecognized AAAs., Results: Most AAA repairs had occurred among men aged 65 to 84 years and categorized as White in large metropolitan areas. The area procedure rates for rAAAs and iAAAs were strongly correlated (R 2  = 0.47). Two other variables-the proportions of persons categorized as White and those aged ≥65 years in a region-identified subgroups within the majority population with a high risk of iAAAs (R 2  = 0.46). Lower rates of clinic visits and AAA ultrasound scans were seen among persons categorized as Black. Several areas with disproportionately higher rAAA/iAAA repair ratios were found, mainly affecting persons categorized as Black., Conclusions: Multiple focused AAA screening strategies could be required to address the disproportionately lower AAA identification among persons categorized as Black., (Published by Elsevier Inc.)

Background: Recent literature and societal recommendations support early revascularization of symptomatic carotid patients over the traditional six-week period. Nonetheless, the timing of these interventions can vary widely among populations. The goal of this study is to identify any factors influencing carotid revascularization during the index hospitalization for patients with symptomatic disease., Methods: The Texas Department of State Health Services database was queried to identify all patients > 45 years old admitted to nonfederal Texas Hospitals between 2009 to 2013 with an admission diagnosis of carotid artery stenosis and either transient ischemic attack (TIA), cerebrovascular accident (CVA), or amaurosis fugax. Diagnoses codes and demographic data were also used to adjust for clinical, social, and demographic factors (including area of residence and treatment). Descriptive statistics and multivariable logistic regression were used to identify significant factors for index admission revascularization., Results: A total of 29,046 symptomatic patients were identified among the 153,484 patients who had an eligible admission diagnosis. This included 16,244 (55.9%) males and 12,802 (44.1%) females. Only 4,594 (15.8%) patients were revascularized during the index hospitalization. The majority of these patients presented with amaurosis (OR 5.58; 95% CI 4.84-6.44) instead of CVAs (OR 0.48; 95% CI 0.45-0.51) or TIAs . Adjusting for hospital volume, insurance coverage, residence, and other clinical factors, rates of index admission carotid intervention remained significantly lower for women (OR 0.85; 95% CI 0.79-0.91), persons categorized as black (OR 0.60; 95% CI 0.53-0.69), and persons categorized as Hispanic (OR 0.77; 95% CI 0.70-0.86)., Conclusions: Gender, race and ethnicity appear to correlate with rates of carotid intervention at index hospitalization despite thorough risk adjustment for clinical, social and demographic factors. Efforts should be directed towards reducing these disparities., (Published by Elsevier Inc.)

Health disparities in vascular surgical care have existed for decades. Persons categorized as Black undergo a nearly twofold greater risk-adjusted rate of leg amputations. Persons categorized as Black, Latinx, and women have hemodialysis initiated via autogenous fistula less often than male persons categorized as White. Persons categorized as Black, Latino, Latina, or Latinx, and women are less likely to undergo carotid endarterectomy for symptomatic carotid stenosis and repair of abdominal aortic aneurysms. New approaches are needed to address these disparities. We suggest surgeons use data to identify groups that would most benefit from medical care and then partner with community organizations or individuals to create lasting health benefits. Surgeons alone cannot rectify the structural inequalities present in American society. However, all surgeons should contribute to ensuring that all people have access to high-quality vascular surgical care., (Copyright © 2021. Published by Elsevier Inc.)

Background: Endovascular intervention is commonly pursued as first-line management of symptomatic, long-segment superficial femoral artery (SFA) disease. The relative effectiveness and comparative long-term outcomes among bare metal stents (BMS), covered stents (CS), and drug-eluting stents (DES) for long-segment SFA lesions remain uncertain., Methods: A retrospective cohort study identified patients with symptomatic SFA lesions measuring at least 15 cm in length who successfully received an endovascular stent (BMS, CS, or DES). The outcomes were patency, patient presentation upon stent occlusion, amputation-free survival (AFS), and all-cause mortality. Proportional hazards regressions and a multinomial logistic regression model were used to control for significant confounders., Results: A total of 226 procedures were analyzed (BMS: 95 [42%]; CS: 74 [33%]; DES: 57 [25%]). There were no significant differences among the 3 stent types with respect to age, prevalence of either diabetes or end-stage renal disease, or smoking history. The median length of the SFA lesion varied across the cohorts (BMS: 28 cm [interquartile range, IQR 20-30]; CS: 26 cm [IQR 20-30]; DES: 20 cm [IQR 16-25]; P = 0.002). The unadjusted primary patency of BMS at 12, 24, and 48 month following index stent placement was 57%, 47%, and 44%, respectively. This is compared to 62%, 49%, and 42% for CS, and 81%, 66%, and 53% for DES, respectively (log-rank P = 0.044). In adjusted models, however, there were no significant differences in primary patency among the stent types. Compared to CS however, DES was associated with improved primary-assisted patency (hazard ratio [HR] for patency loss: 0.35, P = 0.008) and secondary patency (HR: 0.32, P = 0.011). Across the entire follow-up period, stent occlusions occurred in 38 (40%) BMS cases, 42 (57%) CS, and 11 (19%) DES (P < 0.001). Of these, acute limb ischemia (ALI) occurred in 2 (5%) BMS cases, 14 (33%) CS, and 1 (9%) DES (P = 0.010). After adjustment, the relative risk of presenting with ALI as opposed to claudication was 27 times greater among patients re-presenting with occluded CS compared to BMS (P = 0.020). There were no significant differences in AFS or all-cause mortality across the 3 cohorts., Conclusions: For long-segment SFA lesions, DES is associated with improved primary-assisted and secondary patency over long-term follow-up. In the event of stent occlusion, CS is associated with an increased risk of ALI., (Copyright © 2020. Published by Elsevier Inc.)

Background: Transtibial amputations (TTAs) of the leg have been associated with high rates of wound complications. We assessed outcomes of TTAs to determine if bundled interventions implemented at our hospital had an impact on lowering wound complications, including surgical site infections., Methods: We assessed the impact of a surgical site infection prevention bundle (negative-pressure wound therapy, minimizing the use of staples, and a decontamination protocol for methicillin-resistant Staphylococcus aureus) on 90-day wound complications. The year of implementation of the prevention bundle was excluded, and the pre-eras and posteras were defined as the four-year period before and after implementation. The study sample consisted of a single-center cohort, with TTA cases identified using operating room scheduling software., Results: A total of 182 TTAs were performed: 110 in the pre-era and 72 in the postera. The wound complication rate decreased from 22 to 17% despite fewer two-stage operations, less imaging to identify peripheral artery disease, and an increased proportion of patients with end-stage renal disease. Wound complications and revision to a higher level of amputation were more associated with indication (especially no-option peripheral artery disease with ischemic rest pains) than with any particular aspect of surgical technique. The use of drains was associated with reoperations but not higher level revision., Conclusions: Higher rates of wound complications and revision to a higher level of amputations should be expected among patients with no-option peripheral artery disease with ischemic rest pains undergoing TTAs. Drains should be avoided., (Copyright © 2020 Elsevier Inc. All rights reserved.)

Background: The aim of this study was to describe the applicability of the Society for Vascular Surgery (SVS) objective performance goals (OPGs) as a tool to evaluate results in the context of endovascular management of noncomplex and complex patients (i.e., end stage renal disease/history of prosthetic conduit) with chronic limb-threatening ischemia (CLTI)., Methods: Patients diagnosed with CLTI undergoing endovascular procedures from March 2016 to April 2017 were included, and medical records were examined. Patients were categorized as OPG risk (OPGR) and non-OPG risk (nOPGR) groups in accordance with the SVS performance criteria. We compared clinical events between the two groups and then further to the SVS OPGs. Thirty-day outcomes (safety) were major amputation (AMP), major adverse limb events (MALEs), and major adverse cardiovascular events (MACEs), and 1-year outcomes (efficacy) were limb salvage, MALE + 30-day perioperative death (MALE + POD), and survival. Mortality was demonstrated using Kaplan-Meier analysis., Results: A total of 72 patients were included (OPGR = 58.3% vs. nOPGR = 41.7%). Mean follow-up was 20 months (range, 1-40 months). Retrograde pedal access was used in 65.2% of patients. The overall AMP rate was 2.7% (OPGR = 4.7%, nOPGR = 0%, P = 0.225, vs. SVS OPG<3%), MALE was 4.1% (OPGR = 7.1%, nOPGR = 0%, P = 0.135, vs. SVS OPG<8%), and MACE was 6.9% (OPGR = 2.3%, nOPGR = 13.3%, P = 0.071, vs. SVS OPG<8%). The limb salvage was 90.3% (OPGR = 88%, nOPGR = 93.3%, P = 0.46, vs. SVS OPG>84%), MALE + POD was 76.4% (OPGR = 78.6%, nOPGR = 73.4%, P = 0.606, vs. SVS OPG>71%), and survival was 77.7% (OPGR = 83.3%, nOPGR = 70%, P = 0.18, vs. SVS OPG>80%)., Conclusions: The SVS OPGs set appropriate safety and efficacy standards as a bar for new technologies. In this series, endovascular therapy in all-comers exceeded the safety and efficacy endpoints proposed by the limited risk OPG panel., (Copyright © 2020 Elsevier Inc. All rights reserved.)

Background: Surgical outcomes may differ between low-volume and experienced hospitals. We sought to identify characteristics of remote patients-those living more than 50 miles from an experienced center-who underwent leg amputations for peripheral artery disease (PAD) and foot complications at low-volume and experienced hospitals and identify regions of Texas where such patients live., Materials and Methods: Publicly available Texas hospitalization data from 2004 through 2009 were used to identify patients with PAD who underwent leg amputation for foot complications, including foot ulcers, foot infections, and gangrene. Geocoding was used to further identify a subset of remote patients and to estimate distances from zip code of residence to hospital in which care was received., Results: Among all leg amputations, 850 (18.6%) were performed on patients classified as remote, and 3723 (81.4%) were performed on patients classified as nonremote. Compared with nonremote patients, remote patients were more often categorized as white and more frequently received Medicare and/or Medicaid. Of the subset of remote patients, those at low-volume hospitals were older, were less often categorized as Hispanic, more often had Medicaid coverage, were also more frequently admitted through the emergency department, and often had a foot infection compared with those at experienced centers. Geospatial analysis identified five concentrated geographic areas of remote patients who live more than 50 miles from an experienced center., Conclusions: These findings suggest travel distance may at least influence, if not constrain, the choice of hospital for patients with PAD and foot complications. Efforts to decrease leg amputations among remote patients should be focused on five specific geographic areas of Texas., (Published by Elsevier Inc.)

Objective: Bypass graft preservation with wound sterilization using serial antibiotic bead exchange has been described in patients presenting with deep wound infections after extremity bypass. The long-term benefits of this approach remain poorly understood. We examined whether graft preservation and wound sterilization with antibiotic beads affect amputation rates and patient survival., Methods: Patients who underwent operations for aortoiliac or infrainguinal aneurysmal or occlusive arterial disease were retrospectively analyzed. The Infection group included those with patent vascular grafts who developed Szilagyi class II or III deep wound infections within 90 days of index reconstruction and had no evidence of anastomotic or arterial bleeding. All patients in the infection group were managed with graft preservation using serial antibiotic bead exchange every 3 to 5 days until wound cultures became negative. This group was compared with a contemporary group of controls who underwent similar interventions but did not develop wound infections postoperatively. The primary outcome was amputation-free survival, defined as survival without major amputation. Secondary outcomes included major amputations and the occurrence of anastomotic pseudoaneurysms necessitating repair. Inverse propensity score weighting was used for risk adjustment between the groups., Results: Over an 8-year period, we treated 701 patients (infection, 68; controls, 633). Compared with controls, patients in the infection group had a higher body mass index (mean, 28.5 vs 26.3, P = .002) and more prosthetic conduits placed during the index reconstruction. Amputation-free survival for the infection vs the control group was 78 vs 76% at 2 years, 61 vs 66% at 4 years, and 51 vs 57% at 6 years postoperatively (log-rank test, P = .516). Freedom from major amputation for the infection vs the control group was 82 vs 86% at 2 years, 80 vs 82% at 4 years, and 80 vs 76% at 6 years postoperatively (log-rank test, P = .568). In the risk-adjusted model, the presence of treated infection did not affect amputation-free survival (hazard ratio, 0.82; P = .440) or major amputation (hazard ratio, 1.02; P = .949). Anastomotic pseudoaneurysms occurred only in the Infection group (4.4%; P = .001), and were treated with interposition grafts without complications., Conclusions: Bypass graft preservation with wound sterilization using serial antibiotic bead exchange is associated with excellent limb salvage and survival rates, similar to those of noninfected wounds. With the use of this preservation strategy, close follow-up for timely detection of anastomotic pseudoaneurysms is recommended., (Copyright © 2019 Society for Vascular Surgery. Published by Elsevier Inc. All rights reserved.)

Few studies have explicitly identified factors that explain an individual's willingness to engage in community-based exercise for claudication. Identifying the unique characteristics of those inclined toward physical activity would inform interventions that encourage walking. We examined the utility of behavioral economics-related concepts in understanding walking among Veterans with claudication. Patients who received care at the Michael E. DeBakey Veterans Affairs Medical Center in Houston, Texas, were surveyed on symptom severity, behavioral economics, stress, and depression. The primary outcome was a binary variable measuring current walking for exercise and defined as walking for at least 30 minutes every day. Multivariable logistic regression models were used to identify variables, both clinically and statistically significant, at a p -value < 0.05. Between April 2017 and March 2018, we received 148 (30%) responses. A total of 35% ( n = 51) of respondents indicated that they walked recreationally for exercise compared to 65% ( n = 94) who did not. Characteristics that were significantly associated with walking included regularly saving money (adjusted odds ratio (aOR) = 10.7, p = 0.001), seeking complex problem-solving (aOR = 0.12, p = 0.002), and severe symptoms (aOR = 0.24, p = 0.017). Individuals describing a preference for the future rather than immediate benefit also reported currently walking for exercise. Defining the characteristics of those who exercise may help inform strategies designed to increase walking among those who do not adhere to recommendations.

Objective: We sought to determine whether a data-driven scheduling approach improves Operative Suite (OS) efficiency., Background: Although efficient use of the OS is a critical determinant of access to health care services, OS scheduling methodologies are simplistic and do not account for all the available characteristics of individual surgical cases., Methods: We randomly scheduled cases in a single OS by predicting their length using either the historical mean (HM) duration of the most recent 4 years; or a regression modeling (RM) system that accounted for operative and patient characteristics. The primary endpoint was the imprecision in prediction of the end of the operative day. Secondary endpoints included measures of OS efficiency; personnel burnout captured by the Maslach Burnout Inventory; and a composite endpoint of 30-day mortality, myocardial infarction, wound infection, bleeding, amputation, or reoperation., Results: Two hundred and seven operative days were allocated to scheduling with either the RM or the HM methodology. Mean imprecision in predicting the end of the operative day was higher with the HM approach (30.8 vs 7.2 minutes, P = 0.024). RM was associated with higher throughput (379 vs 356 cases scheduled over the course of the study, P = 0.04). The composite rate of adverse 30-day events was similar (2.2% vs 3.2%, P = 0.44). The mean depersonalization score was higher (3.2 vs 2.0, P = 0.044), and mean personal accomplishment score was lower during HM weeks (37.5 vs 40.5, P = 0.028)., Conclusions: Compared to the HM scheduling approach, the proposed data-driven RM scheduling methodology improves multiple measures of OS efficiency and OS personnel satisfaction without adversely affecting clinical outcomes.

Background: Lower extremity amputation rates associated with peripheral arterial disease in Texas are high and vary disproportionately among different populations. We sought to assess the impact of socioeconomic status and health care resource distribution on the geographic prevalence of lower extremity amputation in Texas counties., Materials and Methods: We collated 2005-2009 data on all 254 Texas counties. The primary outcome was the number of nontraumatic lower extremity amputations. Population-adjusted regressions identified factors that could explain increasing amputation rates., Results: We identified 33 counties with population-weighted amputation rates in the highest 25%. These counties had higher rates of diabetes, larger populations of people categorized as black, fewer health care resources, and lower health care utilization. In the presence of more emergency room visits, dual Medicare/Medicaid eligibility decreased total amputations. In counties with more than 70% rural communities, additional primary care providers also significantly decreased amputations per 100,000 residents (mean difference = -0.12, 95% confidence interval: -0.23, -0.0008)., Conclusions: Policy-driven strategic health care resource allocation at the local level may benefit patients in high-need, low-resource areas and promote a reduction in amputations., (Copyright © 2019 Elsevier Inc. All rights reserved.)

Importance: Potentially preventable adverse events remain a formidable cause of patient harm and health care expenditure despite advances in systems-based risk-reduction strategies., Objective: To analyze and describe the incidence of human performance deficiencies (HPDs) during the provision of surgical care to identify opportunities to enhance patient safety., Design, Setting, and Participants: This quality improvement study used a new taxonomy to inform the development and implementation of an HPD classifier tool to categorize HPDs into errors associated with cognitive, technical, and team dynamic functions. The HPD classifier tool was then used to concurrently analyze surgical adverse events in 3 adult hospital affiliates-a level I municipal trauma center, a quaternary care university hospital, and a US Veterans Administration hospital-from January 2, 2018, to June 30, 2018. Surgical trainees presented data describing all adverse events associated with surgical services at weekly hospital-based morbidity and mortality conferences. Adverse events and HPDs were classified in discussion with attending faculty and residents. Data were analyzed from July 9, 2018, to December 23, 2018., Main Outcomes and Measures: The incidence and primary and secondary causes of HPDs were classified using an HPD classifier tool., Results: A total of 188 adverse events were recorded, including 182 adverse events (96.8%) among 5365 patients who underwent surgical operations and 6 adverse events (3.2%) among patients undergoing nonoperative treatment. Among these 188 adverse events, 106 (56.4%) were associated with HPDs. Among these 106 HPD adverse events, a total of 192 HPDs (mean [SD], 1.8 [0.9] HPDs per HPD event) were identified. Human performance deficiencies were categorized as execution (98 HPDs [51.0%]), planning or problem solving (55 HPDs [28.6%]), communication (24 HPDs [12.5%]), teamwork (9 HPDs [4.7%]), and rules violation (6 HPDs [3.1%]). Human performance deficiencies most commonly presented as cognitive errors in execution of care or in case planning or problem solving (99 of 192 HPDs [51.6%]). In contrast, technical execution errors without other associated HPDs were observed in 20 of 192 HPDs (10.4%)., Conclusions and Relevance: Human performance deficiencies were identified in more than half of adverse events, most commonly associated with cognitive error in the execution of care. These data provide a framework and impetus for new quality improvement initiatives incorporating cognitive training to mitigate human error in surgery.

Objective: Placement of large sheaths in the iliac system during fenestrated endovascular aneurysm repair (FEVAR) leads to lower extremity (LE) ischemia that can be associated with serious neurologic complications. We sought to determine the effect of LE ischemic time on neurologic impairment after FEVAR., Methods: Consecutive patients who underwent FEVAR at a single institution were analyzed. LE ischemic time was calculated from the time of large sheath (≥18F) insertion to the time of sheath removal from the iliac arteries that led to continuous LE ischemia. The primary outcome was neurologic impairment defined as any new sensory or motor deficit in either LE. Outcomes were analyzed using descriptive statistics and modeled with logistic regression with interaction terms. Each individual LE was used as a unit of analysis., Results: We examined 101 patients (202 lower extremities) who underwent FEVAR over a 5-year period. The median LE ischemic time was 2.75 hours (range, 0.8-5.2 hours). Neurologic impairment developed in 18 extremities (9%). Of those, 12 (67%) developed mild sensory loss, 6 (33%) complete sensory loss, 4 (22%) loss of proprioception, and 2 (11%) motor dysfunction. Sensory deficit was permanent in four limbs (2%) and motor dysfunction in one limb (0.5%). In all other cases, the neurologic examination returned to baseline by postoperative day 15. Duration of LE ischemic time (odds ratio, 6.3; 95% confidence interval, 3.1-12.4; P < .001) and common iliac artery (CIA) stenosis to a lumen of 8 mm or less (odds ratio, 2.7; 95% confidence interval, 1.5-7.3; P = .002) were independent predictors for the development of neurologic impairment. An interaction term between LE ischemic time and CIA stenosis was statistically significant (P = .042), indicating that the presence of CIA stenosis modifies the effect of LE ischemic time. In those with CIA stenosis to a lumen of 8 mm or less, the risk of neurologic impairment increased rapidly after 2.5 hours of LE ischemia, and became nearly certain after 4 hours of ischemic time. By contrast, patients without CIA stenosis tolerated longer ischemic times and demonstrated a less steep increase in the risk for LE neurologic impairment., Conclusions: LE neurologic impairment after FEVAR is strongly associated with LE ischemic time and CIA occlusive disease to a lumen of 8 mm or less. Our data indicate that, when the LE ischemic time is expected to exceed 2.5 hours (in patients with CIA stenosis) or 3 hours (in patients without CIA stenosis), measures to ensure LE perfusion should be given consideration., (Published by Elsevier Inc.)

Purpose of Review: This paper provides a concise update on the management of peripheral artery disease (PAD)., Recent Findings: PAD continues to denote a population at high risk for mortality but represents a threat for limb loss only when associated with foot ulcers, gangrene, or infections. Performing either angiogram or non-invasive testing for all patients with foot ulcers, gangrene, or foot infections will help increase the detection of PAD, and refined revascularization strategies may help optimize wound healing in this patient group. Structured exercise programs are becoming available to more patients with claudication as methods to improve adherence to community-based exercise programs will improve. Finally, ensuring more patients with PAD receive aspirin therapy and statins may improve long-term survival, while further research will help determine if adding newer antiplatelet or anticoagulant medications may reduce leg amputations in selected patients. Clinicians should have a low threshold to obtain an angiogram and to pursue revascularization in patients with foot ulcers, gangrene, or foot infections. In patients with claudication, clinicians should maximize the benefits derived from exercise therapy and medical management before offering percutaneous or surgical revascularization.

Background: Behavioral economics theories suggest that a preference for delayed benefits promotes positive behavioral change, a concept relevant to both smoking cessation and community-based exercise regimens for claudication. Given the high rate of smoking among older veterans, we were interested in examining the association between smoking cessation, exercise regimen adherence, and preferences for delayed versus immediate benefits., Methods: Between April 2017 and March 2018, patients with claudication at the Michael E. DeBakey Veterans Affairs Medical Center in Houston, Texas, received questionnaires collecting information on social, behavioral, and psychological characteristics. A dual validation system, via the electronic medical record and survey data, measured the primary outcome-smoking cessation versus current smoking. Self-reported physical activity was measured through the validated Ainsworth's compendium of Physical Activities and binary survey questions. The Walking Impairment and Barratt's Impulsivity Questionnaires measured subjective symptom severity and behavioral economics factors, respectively. Multivariable, logistic regression models identified significant associations., Results: The survey was mailed to 500 patients who met the eligibility criteria. We received responses from 148 individuals (30%), and 67 of 141 (48%) indicated that they had successfully quit smoking. In unadjusted comparisons, the median cognitive complexity score in the smoking cessation group was higher than that in the current smoking group. A greater proportion of patients who reported walking for exercise (n = 46) also reported successful smoking cessation (28/46, 61%). Among those who were not walking for exercise (n = 88), more individuals reported current smoking (49/88, 56%). In the multivariable model, individuals who had successfully stopped smoking were older (odds ratio [OR]: 7.59, P < 0.001), more likely to walk for exercise (OR: 3.94, P = 0.009), more interested in the future than in the present (OR: 1.73, P = 0.030), and more likely to regularly save money (OR: 3.49, P = 0.046)., Conclusions: We found that participants who reported successful smoking cessation were more likely to report walking for exercise. Our findings suggest that adherence to walking may be less challenging for patients who have already successfully implemented and continue to implement another beneficial health behavior (smoking cessation). Patients with claudication who are current smokers may be less likely to adopt exercise recommendations., (Published by Elsevier Inc.)

We compared paired operative bone cultures (initial operation and reoperation) for 35 patients who experienced foot osteomyelitis treatment failure at a single hospital. Concordance was poor (kappa = 0.180). Staphylococcus aureus, gram negatives, and anaerobes were the most common discordant bacteria seen at reoperation, while Enterococcus was the most persistent.

Recent studies have shown an association between infections, such as influenza, pneumonia, or bacteremia, and acute cardiac events. We studied the association between foot infection and myocardial infarction, arrhythmia, and/or congestive heart failure. We analyzed the records of 318 consecutive episodes of deep soft tissue infection, gangrene, and/or osteomyelitis in 274 patients referred to a vascular surgery service at a tertiary center. We identified 24 acute cardiac events in 21 of 318 (6.6%) episodes of foot infection or foot gangrene. These 24 events included 11 new myocardial infarctions (3.5%), 8 episodes of new onset or worsening congestive heart failure (2.5%), and 5 new arrhythmias (1.6%). Tachycardia and systemic inflammatory response syndrome were associated with acute cardiac events ( P < .05 for each). The 1-year survival of patients with acute cardiac events was 50.4%, significantly lower than the 91.7% 1-year survival of patients without acute cardiac events ( P < .0015). Acute cardiac complications are not uncommon among patients presenting with severe foot infection and are associated with a high 1-year mortality. Primary care physicians, cardiologists, and vascular and orthopedic surgeons must keep a high index of suspicion for the occurrence of an acute cardiac event.

Background: Despite advances in endovascular therapy, infrainguinal bypass continues to play a major role in achieving limb salvage. In this study, we sought to compare outcomes of infrainguinal bypass in patients with limb-threatening ischemia who presented with or without foot infection., Methods: We conducted a retrospective cohort study of patients who underwent infrainguinal bypass for chronic limb-threatening ischemia at a single institution. End points of interest included long-term mortality, 45-day readmission, postoperative length of stay (LOS), major amputation, and time to wound healing. Multivariable Cox, logistic, and robust regressions were used to model time to event outcomes, readmission rates, and LOS., Results: There were 454 infrainguinal bypass procedures analyzed. Demographics and baseline characteristics were similar, except congestive heart failure and diabetes were more common in the infection group. Presence of foot infection had no impact on mortality (hazard ratio [HR], 0.78; P = .243). Significant predictors of long-term mortality included increasing age, hypoalbuminemia, and congestive heart failure; preoperative use of clopidogrel was protective. Presence of foot infection was an independent predictor of major amputation. In the multiple regression model, the presence of foot infection was independently associated with amputation rate (HR, 2.14; 95% confidence interval, 1.42-3.22; P < .001); use of venous conduit and increasing age and body mass index were protective. Foot infection was an independent predictor of prolonged LOS (mean LOS was 1.54 days longer in patients with vs those without infection; P = .001). Other independent predictors of prolonged LOS included intraoperative blood loss and reoperation; history of continuous preoperative aspirin use and normal baseline renal function and albumin levels were associated with decreased LOS. Readmission was influenced by reoperation (odds ratio [OR], 2.51; P < .001) but not by presence of foot infection (OR, 1.21; P = .349). There was a strong trend for prolonged wound healing time in patients with diabetes (HR, 1.58; P = .05) but not in those with foot infection (OR, 0.74; P = .36)., Conclusions: Among patients requiring infrainguinal bypass for limb-threatening ischemia, infection was more common in patients with diabetes and was a significant predictor of major amputation and prolonged LOS. Infection was not predictive of mortality, wound healing time, or readmission. These findings lend support to the inclusion of infection in risk stratification schemes for patients with chronic limb-threatening ischemia, as recommended in the Society for Vascular Surgery Wound, Ischemia, and foot Infection (WIfI) classification system, because of its adverse impacts on limb salvage., (Copyright © 2018. Published by Elsevier Inc.)

Objective: In the absence of suitable autologous vein, the use of prosthetic grafts for infragenicular bypasses in peripheral arterial disease has become standard practice. The purpose of this study was to investigate whether creating a vein patch at the distal anastomosis would further improve patency and freedom from major adverse limb events (MALEs). Furthermore, we sought to investigate whether the use of a distal vein patch (DVP) was associated with lower rates of acute limb ischemia (ALI) for those presenting with occluded prosthetic bypass graft., Methods: The cases of all patients undergoing infragenicular prosthetic bypass grafts between January 2009 and July 2016 were retrospectively reviewed. Demographics of the patients, clinical data, and outcomes (graft patency and MALEs) were collected. Patients were compared according to treatment group (DVP vs no DVP). A Cox regression analysis was used to analyze follow-up results., Results: During the study period, a total of 373 patients underwent infragenicular bypass at our institution; of those, 93 (24.9%) had prosthetic grafts (DVP, 39; no DVP, 54). Overall, 92 (98.9%) patients were male; the mean age was 63.3 ± 6.6 years and did not differ between the two groups. Patients undergoing prosthetic bypass with DVP were more likely to have chronic obstructive pulmonary disease (38.5% vs 14.8%; P = .009) and less likely to have chronic kidney disease (2.6% vs 20.4%; P = .011). Follow-up data were available for all patients for a median of 7.8 months (range, 1-89 months). After adjustment for differences in demographics and clinical data between the two groups, when outcomes were analyzed, MALEs were significantly lower in the DVP group (35.9% vs 57.4%; odds ratio [OR], 0.4; 95% confidence interval [CI], 0.2-0.9; P = .041). Similarly, reintervention rates were significantly lower in the DVP group (30.8% vs 50.0%; OR, 0.4; 95% CI, 0.2-0.9; P = .044). There was a trend toward higher primary patency in the DVP group (46.2% vs 35.2%; OR, 1.5; 95% CI, 0.7-3.5; P = .206) and lower rates of ALI after bypass occlusion (30.0% vs 42.9%; OR, 0.6; 95% CI, 0.2-1.8; P = .345). A Cox regression time-to-event analysis revealed late separation of freedom from MALEs for DVP relative to no DVP (log rank, P = .269)., Conclusions: In this evaluation of infragenicular prosthetic bypass grafts, the creation of a vein patch at the distal anastomosis was associated with lower reintervention rates and a trend toward improved primary patency and MALEs. Furthermore, for those presenting with occluded prosthetic bypass graft, the use of a DVP was associated with a trend toward lower rates of ALI., (Published by Elsevier Inc.)

Background: The existence of racial and ethnic disparities in leg amputations rates is well documented. Despite this, approaches to addressing these alarming disparities have been hampered by the inability to identify at-risk individuals in a region and design targeted interventions. We undertook this study to identify small geographic areas in which efforts focused on high-risk individuals with peripheral artery disease (PAD) could address disparities in leg amputation rates., Methods: We used de-identified Texas state admission data to identify PAD-related admissions associated with an initial revascularization (leg angioplasty or leg bypass) or an primary leg (above-ankle) amputation between from 2004 through 2009., Results: 21,273 major initial procedures were performed in Texas from 2004 through 2009 for PAD-related diagnoses, including 16,898 revascularizations and 4,375 leg amputations. A multivariate logistic regression demonstrated that an initial leg amputations done without revascularization was significantly associated with, among other variables: people categorized as black (odds ratio [OR] 1.79) or Hispanic (OR 1.42); those with Medicaid coverage (OR 1.89); and those treated at low volume hospitals (OR 1.78; p<0.001 for all). Four geographic regions were identified with significantly higher risk-adjusted leg amputation rates. Of the 349 Texas hospitals performing major procedures, 72 (21%) reported no revascularization procedures during the six year period studied., Conclusions: Prevention efforts directed at specific geographic areas may be more likely to reach at-risk people with PAD and thereby reduce leg amputations disparities in Texas. Such efforts might also find strategies to direct patients toward higher volume centers with higher revascularization rates., Competing Interests: Potential conflicts of interest: none.

Background: Wound complications remain a significant source of morbidity for patients undergoing open infra-inguinal re-vascularization. The purpose of this study was to determine the impact of several infection-control strategies on post-operative wound complications after open infra-inguinal re-vascularization., Methods: A retrospective cohort study was conducted among all patients who underwent an open infra-inguinal re-vascularization procedure before and after 2014. Since 2014, we have implemented strategies to reduce post-operative wound complications, including: (1) Decreasing the use of incisional skin staples, (2) increasing the use of negative pressure wound therapy (NPWT) dressings, and (3) implementing an outpatient elective decontamination protocol for methicillin-resistant Staphylococcus aureus. "Pre-era" is defined as the period between January 2012 and December 2013, before the implementation of infection control strategies; "Post-era" is between January 2015 and August 2016, after implementation. The primary outcome of interest is 30-day wound complications (infection or dehiscence). Multi-variable logistic regression analysis was used to identify significant predictors of wound-related complications between the two cohorts. Propensity score adjustment controlled for baseline patient characteristics, peri-operative variables, and surgeon experience., Results: A total of 338 open infra-inguinal procedures were performed: 175 in the pre-era and 163 in the post-era. Chlorhexidine skin preparation was used in the majority (321 [95%]) of cases. Comparing the periods, the post-era is characterized by a significant decrease in the use of groin staples (118 [67%] vs. 51 [31%], p < 0.001), and an increased application of NPWT dressings (6 [4%] vs. 66 [43%], p < 0.001). Thirty-five (37%) outpatient elective cases received the pre-operative decontamination protocol in the post-era. Compared with the pre-era, there was a decrease in the 30-day rate of wound complications (68 [39%] to 42 [26%], p = 0.011), and infection-related re-admissions (31 [17.7%] to 21 [12.9%], p = 0.220). When adjusting for patient characteristics, operative variables, and surgeon experience, post-era had significantly lower wound complications (odds ratio [OR] 0.33, p = 0.002) and re-operations (OR 0.16, p = 0.007). Among outpatient elective cases, the decontamination protocol was also independently associated with these two outcomes (wound complications: OR 0.05, p = 0.006; re-operations: 0.06, p = 0.002). The use of groin staples was an independent predictor of deep groin infections (OR 248, p < 0.001) and re-operations (OR 8.16, p = 0.032)., Conclusions: Wound complications after open infra-inguinal re-vascularization have decreased significantly after the implementation of several infection-control strategies. Findings suggest that skin staples should be avoided in groin wounds, and anti-staphylococcal decontamination protocols decrease wound complications and prevent re-operations.

Objective: Published data suggest that permissive anemia strategies that allow nadir hemoglobin (nHb) values of 7 g/dL or lower are safe in a variety of clinical settings. The appropriateness of these strategies in patients at high risk for adverse postoperative cardiac events remains unclear. We sought to determine the combined effect of postoperative nHb and cardiac risk status on major complications after vascular surgical interventions., Methods: This was a single-institution retrospective analysis of consecutive patients who underwent elective open procedures for occlusive vascular disease and aneurysm repair, either open or endovascular. The Revised Cardiac Risk Index (RCRI) was used to assess baseline cardiac risk. Primary outcome was a composite end point of mortality or major ischemic events (myocardial infarction, stroke, acute kidney injury, or coronary revascularization) within 90 days from the index operation. Secondary outcomes included intensive care unit (ICU) length of stay (LOS) and 90-day respiratory complications (pneumonia, ventilator dependence for >48 hours postoperatively, or reintubation). Hierarchical multivariable regression was used to model each outcome with adjustment for age, type of operation, baseline comorbidities, and intraoperative covariates., Results: We analyzed 2508 operations performed during 8 years in 2106 patients with a mean age of 67 years (range, 45-90 years). In the fully adjusted multivariable model, lower values of nHb increased the risk of the primary composite end point (odds ratio [OR], 1.24; P < .001, representing a 24% increase in the odds of the composite end point for each 1-g/dL increase in nHb). In the same model, RCRI class II (OR, 1.8; P < .001), class III (OR, 2.06; P < .0001), and class IV (OR, 2.35; P < .0001) were associated with progressively increasing odds of the composite end point compared with RCRI class I. An interaction term between transfusion and nHb was not significant statistically, indicating that the harmful effect of anemia was independent of blood transfusion. Lower values of nHb also increased the risk of respiratory complications (OR, 1.41; P = .002) and ICU LOS (average 2.6-day increase per 1-g/dL increase of nHb; P < .0001)., Conclusions: Postoperative anemia increases the rate of early postoperative mortality and major ischemic events, particularly in patients at higher baseline cardiac risk. It also adversely affects respiratory complications and ICU LOS. Until a randomized trial definitively settles the issue, restrictive transfusion strategies should be practiced with caution in patients undergoing major vascular interventions., (Published by Elsevier Inc.)

We examined how pain beliefs are related to symptom severity, expectations of risk/benefits, and baseline physical activity among claudicants. Eligible patients at the Michael E DeBakey Veterans Affairs Medical Center were administered questionnaires that measured: fear-avoidance beliefs (Fear-Avoidance Beliefs Questionnaire [FABQ]), walking impairment, baseline physical activity, claudication type, and risk/benefit attitudes. Among 20 participants, the median age was 69 years (IQR: 66-75). In our efforts to understand how fear-avoidance beliefs influenced physical activity among people with claudication, we found that 12 out of 19 participants (63%) thought that the primary etiology of their pain was walking, while 18 (out of 20) (90%) people thought that walking would exacerbate their leg symptoms - suggesting that there was some confusion regarding the effects of walking on claudication. Those who expected that walking would benefit their symptoms more than surgery reported fewer fear-avoidance beliefs ( p=0.01), but those who believed that walking would make their leg pain worse expected greater benefit from surgery ( p=0.02). As symptom severity increased, fear-avoidance beliefs also increased ( p=0.001). The association between symptom severity and fear-avoidance beliefs indicates that as pain or impairment increases, the likelihood of avoiding behaviors that are thought to cause pain might also increase. Accounting for pain-related beliefs when recommending physical activity for claudication should be considered.

Background: Sustained efforts at preventing diabetic foot ulcers (DFUs) and subsequent leg amputations are sporadic in most health care systems despite the high costs associated with such complications. We sought to estimate effectiveness targets at which cost-savings (i.e. improved health outcomes at decreased total costs) might occur., Methods: A Markov model with probabilistic sensitivity analyses was used to simulate the five-year survival, incidence of foot complications, and total health care costs in a hypothetical population of 100,000 people with diabetes. Clinical event and cost estimates were obtained from previously-published trials and studies. A population without previous DFU but with 17% neuropathy and 11% peripheral artery disease (PAD) prevalence was assumed. Primary prevention (PP) was defined as reducing initial DFU incidence., Results: PP was more than 90% likely to provide cost-savings when annual prevention costs are less than $50/person and/or annual DFU incidence is reduced by at least 25%. Efforts directed at patients with diabetes who were at moderate or high risk for DFUs were very likely to provide cost-savings if DFU incidence was decreased by at least 10% and/or the cost was less than $150 per person per year., Conclusions: Low-cost DFU primary prevention efforts producing even small decreases in DFU incidence may provide the best opportunity for cost-savings, especially if focused on patients with neuropathy and/or PAD. Mobile phone-based reminders, self-identification of risk factors (ex. Ipswich touch test), and written brochures may be among such low-cost interventions that should be investigated for cost-savings potential., (Published by Elsevier Inc.)

Background: Conflicting studies exist regarding the impact of methicillin-resistant Staphylococcus aureus (MRSA) on increased time to wound healing, future need for surgical procedures, and likelihood of treatment failure in patients with diabetic foot osteomyelitis. The purpose of this study is to determine the overall significance of MRSA in predicting treatment failure in bone infections of the foot and to determine an appropriate pre-operative and empiric post-operative antibiotic regimen., Patients and Methods: Patients presenting with an initial episode of "probable" or "definite" foot osteomyelitis were included for review and analysis if the following criteria were met: (1) Osteomyelitis occurred in the foot (i.e., distal to the malleoli of the ankle); episodes occurring above the ankle were excluded. (2) Patients received either no antibiotics or only oral antibiotics for long-term treatment; episodes managed with long-term parenteral antibiotics were excluded. (3) The infection was managed initially with medical therapy or conservative surgical therapy; episodes managed with major (above-ankle) amputation as the initial treatment were excluded. The primary objective of this study was to assess whether episodes of foot osteomyelitis associated with MRSA resulted in treatment failure more frequently than not., Results: Of 178 episodes included in the study, 50 (28.1%) episodes had treatment failure. Median time-to-treatment failure was 60 days (range 7-598 days). In 28.1% (9/32 episodes) in which treatment failure occurred and 39.0% (41/105) episodes in which no treatment failure occurred, MRSA was present. The presence of MRSA was not significantly associated with treatment failure (p = 0.99)., Conclusions: The presence of MRSA in bone culture and whether antibiotic use had anti-MRSA activity was not associated with increased treatment failure of diabetic foot osteomyelitis in our institution. Empiric antibiotic coverage of MRSA may not be necessary for many patients presenting with foot osteomyelitis.

We sought to identify factors associated with treatment failure and leg amputations among those patients who presented with foot osteomyelitis. Characteristics, treatments, and outcomes for all patients treated for probable or definite foot osteomyelitis (per consensus definition) between January 2011 and March 2015 were reviewed. Multivariate Cox regression models were used to identify risk factors for treatment failure (unanticipated resection of additional bone or leg amputation) and of leg amputation alone. A total of 184 episodes of foot osteomyelitis met inclusion criteria. Treatment failure occurred in 53 (28.8%) and leg amputation in 21 (11.4%). Risk factors for treatment failure included severe/unaddressed peripheral artery disease, homelessness, Pseudomonas aeruginosa or Escherichia coli bone isolates, serum albumin <2.8 mg/dL, hallux involvement, insulin therapy, 60 or more pack-years smoking, and <7 days of directed antibiotic therapy for a positive bone margin. Delayed primary wound closure (ie, staged operations) had significantly lower treatment failure risk. Unanticipated resection of bone was not associated with leg amputation. Foot osteomyelitis treatment failure is common. Various factors can help identify those at risk for treatment failure and/or leg amputation, and further studies should focused whether initial management or follow-up should change when these factors are present.

Background: Risk of progression to various stages of chronic kidney disease (CKD) after endovascular aortic aneurysm repair (EVAR) is unknown. This study estimates progression rates to stage 3 and 4 CKD after EVAR and identifies potential predictors for progression., Methods: EVAR cases (2006-2012) were retrospectively reviewed. Freedom of progression to CKD was estimated using Kaplan-Meier analysis, and predictors for progression were identified using Cox proportional hazards model., Results: Two hundred and twelve consecutive patients at a single academic institution underwent EVAR for infrarenal aneurysms. Estimated freedom from progression to stage 3 CKD was 80%, 76%, and 63% at 6, 12, and 18 months, respectively, and for stage 4, 97%, 96%, and 93% at 6, 12, and 18 months, respectively. Stage 3 CKD predictors of progression included age (odds ratio (OR): 1.106, p = 0.001), diabetes (OR: 3.052, p = 0.04), perioperative use of angiotensin converting enzyme inhibitors or angiotensin receptor blockers (OR: 3.249, p = 0.02), and operative blood loss (OR: 1.002, p < 0.01). Stage 4 predictors included preoperative hemoglobin (OR: 0.473, p = 0.04) and baseline renal function (OR: 0.928, p = 0.001). Intraoperative contrast administration did not impact CKD development., Conclusions: Progression to stage 3 CKD after EVAR occurs more frequently and at a higher rate compared with progression to stage 4. Different risk factors are associated with progression to each of those stages of CKD., (© The Author(s) 2016.)

Background: Patients with diabetic foot ulcers (DFUs) should be evaluated for peripheral artery disease (PAD). We sought to estimate the overall diagnostic accuracy for various strategies that are used to identify PAD in this population., Methods: A Markov model with probabilistic and deterministic sensitivity analyses was used to simulate the clinical events in a population of 10,000 patients with diabetes. One of 14 different diagnostic strategies was applied to those who developed DFUs. Baseline data on diagnostic accuracy of individual noninvasive tests were based on a meta-analysis of previously reported studies. The overall sensitivity and cost-effectiveness of the 14 strategies were then compared., Results: The overall sensitivity of various combinations of diagnostic testing strategies ranged from 32.6% to 92.6%. Cost-effective strategies included ankle-brachial indices for all patients; skin perfusion pressures (SPPs) or toe-brachial indices (TBIs) for all patients; and SPPs or TBIs to corroborate normal pulse examination findings, a strategy that lowered leg amputation rates by 36%. Strategies that used noninvasive vascular testing to investigate only abnormal pulse examination results had low overall diagnostic sensitivity and were weakly dominated in cost-effectiveness evaluations. Population prevalence of PAD did not alter strategy ordering by diagnostic accuracy or cost-effectiveness., Conclusions: TBIs or SPPs used uniformly or to corroborate a normal pulse examination finding are among the most sensitive and cost-effective strategies to improve the identification of PAD among patients presenting with DFUs. These strategies may significantly reduce leg amputation rates with only modest increases in cost., (Published by Elsevier Inc.)

Background: The appropriateness of percutaneous intervention for moderate to severe carotid in-stent restenosis (C-ISR) is unclear. We therefore sought to compare stroke/death/myocardial infarction (MI) rates between percutaneous interventions and nonoperative management for ≥50% C-ISR., Methods: We performed a single-center retrospective review of consecutive patients presenting with ≥50% C-ISR to the vascular surgery service. Demographics, comorbidities, and intraoperative and postoperative variables were obtained. The degree of stenosis was verified by review of digital subtraction or computed tomography angiograms. The primary outcome was stroke/death/MI after the diagnosis of ≥50% C-ISR. χ 2 , Kruskal-Wallis, and Kaplan-Meier analysis was used to quantify outcomes of the patients treated percutaneously vs nonoperatively., Results: During a 13-year period, 59 patients (75 C-ISRs) presented with ≥50% C-ISRs (n = 58 male [98%]; n = 57 C-ISRs asymptomatic [76%]) with a median age of 67.5 years (62.8-74.6). The initial pathologic process underlying the original stent was atherosclerosis in 33 (70%), radiation induced in 10 (21%), prior carotid endarterectomy in 4 (9%), and unknown in 28 (37%). Forty C-ISRs underwent a percutaneous intervention (19 percutaneous angioplasty only [48%]; 21 repeated stent and percutaneous angioplasty [52%]). Median follow-up for the entire cohort was 948 days (283-2322) and similar between the intervention and nonintervention arms. There were no significant differences between the arms with respect to age (P = .16), medical comorbidities (P > .05), original stent type (P = .46), or clopidogrel use (P = .74). At 30 days, there was one stroke and subsequent death in the intervention arm and none in the nonintervention arm. During the follow-up period, a median of 1.0 procedure was required to maintain patency. By Kaplan-Meier analysis, there were no statistically significant differences between the intervention and nonintervention arms with respect to stroke/death/MI as a composite or any of the individual components at last follow-up (P = .82). Kaplan-Meier estimated patency was not significantly superior in the intervention vs the nonintervention arm (8.0 years ± 1.1 vs 5.3 years ± 0.7; P = .14)., Conclusions: Over 13 years, percutaneous interventions for ≥50% C-ISR were safe and durable. However, interventions fail to improve long-term stroke/death/MI or patency rates relative to nonintervention. Intervention for C-ISR may not be necessary, although future appropriately powered, prospective trials will be necessary to confirm these findings and to determine the appropriateness of interventions for C-ISR., (Published by Elsevier Inc.)

Background: The aim of this study was to develop consensus statements that may help share or even establish 'best practices' in the surgical aspects of managing diabetic foot osteomyelitis (DFO) that can be applied in appropriate clinical situations pending the publication of more high-quality data., Methods: We asked 14 panelists with expertise in DFO management to participate. Delphi methodology was used to develop consensus statements. First, a questionnaire elicited practices and beliefs concerning various aspects of the surgical management of DFO. Thereafter, we constructed 63 statements for analysis and, using a nine-point Likert scale, asked the panelists to indicate the extent to which they agreed or disagreed with the statements. We defined consensus as a mean score of greater than 7.0., Results: The panelists reached consensus on 38 items after three rounds. Among these, seven provide guidance on initial diagnosis of DFO and selection of patients for surgical management. Another 15 statements provide guidance on specific aspects of operative management, including the timing of operations and the type of specimens to be obtained. Ten statements provide guidance on postoperative management, including wound closure and offloading, and six statements summarize the panelists' agreement on general principles for surgical management of DFO., Conclusions: Consensus statement on the perioperative management of DFO were formed with an expert panel comprised of a variety of surgical specialties. We believe these statements may serve as 'best practice' guidelines until properly performed studies provide more robust evidence to support or refute specific surgical management steps in DFO.

Objective: To understand the relationship between self-perceived severity of intermittent claudication and various associated nonclinical factors, we examined how correlates in domains of physical activity (ie, clinical, psychological, behavioral, social, and environmental factors) relate to exertional limb symptoms., Methods: A survey was administered to individuals with intermittent claudication during their initial outpatient assessment. The subjects' self-reported exertional limb symptom severity and classic-versus-atypical claudication classification was based on the Walking Impairment Questionnaire (WIQ) and San Diego Claudication Questionnaire (SDCQ), respectively. We evaluated psychosocial and environmental factors, osteoarthritis symptoms, health, behaviors, and beliefs. Logistic and linear regressions identified factors with a strong independent association with total WIQ scores and the SDCQs., Results: A cohort of 102 subjects (99.0% male) was enrolled in the study. The median age was 65 years with a median ankle-brachial index of 0.69. Forty-three subjects (43%) had "typical" claudication per SDCQs. Individuals with atypical claudication were more likely to report higher Aberdeen Clinical Back Pain Questionnaire scores (odds ratio, 1.04; P = .04) and no depressive symptoms (odds ratio, 8.30; P = .03). Exertional limb symptom severity among the entire cohort was significantly associated with increasing osteoarthritis symptoms (P <.001), age (P = .02), a reserved personality (P = .008), and the belief that an exercise regimen would not improve symptoms (P = .005), self-perceived levels of boredom (P = .002), and the belief that exercise (P = .002) was the best way to improve symptoms were associated with decreased symptom severity. When restricted to those with atypical pain, significant factors associated with increasing exertional symptom severity included age greater than 60 years (P = .005), osteoarthritis (P = .02), alcohol use (P = .01), belief that exercise would not improve walking (P = .03), and difficulty walking around the neighborhood (P = .02). When restricted to those with classic claudication, significant factors associated with increasing exertional limb symptom severity included frequent pain or aching in the calves while walking or sitting (P = .03 [walking]; P = .01 [sitting]) and occasional morning joint stiffness (P = .007). Exertional limb symptom severity was also associated with high limitations at home (P = .003) and a belief that exercise would not improve walking (P = .005) among those with classic claudication., Conclusions: Symptom severity and type of pain are associated with a number of nonclinical factors. A multidomain approach, as indicated by the models above, would benefit the continuum of care for intermittent claudication, where management is integrated and coordinated among multiple lines of care., (Published by Elsevier Inc.)

Compartment syndrome of the leg is a well-recognized complication known to follow urgent revascularization done for acute limb ischemia, but compartment syndrome of the foot has not been reported after the ischemia-reperfusion sequence. Herein we report a case of foot fasciotomy done for compartment syndrome that occurred after urgent revascularization. We suggest that foot fasciotomies should be considered in particular circumstances of acute lower leg ischemia, such as infrapopliteal thromboembolic events, prolonged ischemia, and persistent or worsening foot symptoms that follow revascularization and calf fasciotomies., (Published by Elsevier Inc.)

Objective: Screening for common carotid artery (CCA) stenosis with duplex ultrasound (DUS) velocity criteria alone can be limited by within-patient and between-patients hemodynamic variability. This study aimed to evaluate inter-CCA velocity ratio criteria to predict high-grade CCA stenosis., Methods: This was a retrospective review of consecutive patients who underwent computed tomography angiography and DUS peak systolic velocity (PSV) measurements of bilateral CCAs, independently recorded, between 2008 and 2014. Patients with dampened CCA waveforms on DUS composed group B. The remainder without dampened waveforms constituted group A. Inter-CCA PSV ratios were calculated by dividing the higher CCA PSV by the lower one of the other side, so the ratios would always be ≥1. Ratios were subsequently paired with each respective unilateral CCA diameter stenosis and differential bilateral CCA diameter stenosis. A quadratic regression model was fitted to predict unilateral and differential stenosis. Receiver operating characteristic curve was used to determine optimal ratios for ≥50% and ≥80% CCA stenosis. The study excluded patients with carotid artery occlusion., Results: From a total of 201 patients, 193 patients were included in group A and 8 in group B. Within group A, 31 patients had ≥50% unilateral stenosis and 17 had ≥50% differential stenosis. All stenoses ≥50% were identified on the same side with the higher PSV. Inter-CCA PSV ratio predicted ≥50% unilateral (r(2) = 0.536; P < .001) and differential stenosis (r(2) = 0.581; P < .001). In group B, all patients had ≥60% stenosis that was near or involved the vessel origin. An increasing inter-CCA PSV ratio showed a trend toward contralateral high-grade stenosis (r(2) = 0.596; P = .1). Receiver operating characteristic curves showed an optimal threshold CCA ratio ≥2.16 for ≥50% unilateral stenosis with 92% accuracy, 62% sensitivity, and 98% specificity (area under curve = 0.854; 95% confidence interval, 0.759-0.948) and a ratio ≥2.62 for ≥50% differential stenosis with 97% accuracy, 83% sensitivity, and 98% specificity (area under curve = 0.94; 95% confidence interval, 0.835-1)., Conclusions: DUS-based CCA PSV ratio can accurately predict unilateral and differential high-grade CCA stenosis. Also, in patients with unilateral dampened waveforms, it implied contralateral severe proximal stenosis. This parameter should be further validated in prospective studies and may serve as an adjunct screening tool to detect high-grade CCA stenosis., (Published by Elsevier Inc.)

Background: Observational data indicate that carotid artery stenting (CAS) is associated with higher incidence of subclinical cerebral microemboli than carotid endarterectomy (CEA). We hypothesized that CEA would be associated with superior performance on detailed domain-specific cognitive testing compared with CAS., Methods: Patients with >80% asymptomatic carotid artery stenosis were randomized to CEA or CAS with side of stenosis balanced across condition. A robust battery of tests was used to assess the cognitive domains of attention, memory, mood, visual-spatial skills, motor ability, processing speed, and executive functioning ≤10 days preoperatively and postoperatively at 6 weeks and 6 months. Tests were administered using standardized conditions and were scored by individuals blinded to treatment allocation., Results: Baseline cognitive performance was similar between CAS (n = 29) and CEA (n = 31) groups (P > .05). Relative to baseline, verbal and visual memory and attention functions substantially improved in the CAS and CEA groups at 6 months (multiple cognitive tests achieved statistical significance). Compared with CEA, cognitive processing speed (Stroop Color test: 9.0 vs 7.3, P = .04; and Stroop Word test: 9.0 vs 7.4, P = .05) was superior in the CAS group at 6 weeks. Executive functioning (phonemic verbal fluency: 10.6 vs 8.4, P = .043) and motor function (Grooved Pegboard of nondominant extremity: 45.7 vs 38.9, P = .022) were also superior in the CAS group at 6 months. Tests of attention, memory, and visual-spatial skills were similar between CAS and CEA patients at 6 weeks and 6 months., Conclusions: Carotid revascularization improves memory and attention within the first 6 postoperative months. Compared with CEA, CAS produces improvements in cognitive processing speed, executive functioning, and motor function., (Published by Elsevier Inc.)

The thickened intimal flap present in cases of chronic aortic dissection can present a challenge to attempts at endovascular stent graft treatment performed for subsequent aneurysmal degeneration by precluding adequate landing zones for the endograft and by constraining the endograft from full expansion. In this report we describe our technique and outcome for longitudinal endovascular fenestration of chronic aortic dissection flaps to facilitate endovascular stent graft treatment for thoracic aortic aneurysms developing after aortic dissection., (Copyright © 2015 Society for Vascular Surgery. All rights reserved.)